Fresno - New Student Enrollment Application (Adults): 2022-23

Fresno Site 2022 – 2023 Enrollment Application

(for adult students 18 and older)
Dear Prospective Student,

Thank you for your interest in YouthBuild Charter School of California (YCSC). To consider your application, all of the following documents are required. Please return this checklist with your application and all documents for consideration. Incomplete applications will not be accepted.
- Signed Letter / Proof of Acceptance to local YouthBuild program
- Confirm student is NOT enrolled in two schools at the same time. PAR and/or Withdraw Slip from previous school with an exit date will be acceptable
- Completed Enrollment Application:
  - YCSC Enrollment Application
  - Student Agreement
  - Student Release Form
  - YouthBuild Emergency Card
- Household Income Data Collection Form
- Birth Certificate – COPY
- Identification card reflecting current address: Driver License or CA ID - COPY
- Utility Bill – COPY
- Proof of Household Income (e.g. Check stub, MediCal Lifeline or Public Benefit Award Letter, Tax Return or No Income Certification) - COPY
- Special Education Documents (IEP) and 504 Plan or Opt Out Letter – COPY
- Immunization Records - TDAP IS A REQUIREMENT (Minors Only)
- Official School Transcripts
Once you have completed this online application you must submit the above documents to your counselor in order to complete your enrollment.

If you are currently homeless, you may be exempt from having to submit all of the above documents prior to enrollment. Please talk to your counselor if you are having trouble obtaining the above documents.

PREVIOUS SCHOOLING INFORMATION
How many credits have you completed? (Provide your best estimate if you aren't sure.) *
Have you been enrolled in ANY school during THIS school year? *

Yes, I was enrolled at another school during THIS school year. No, I was not been enrolled at any school THIS school year.
List all previous high schools you attended (most recent first). If you have not attended high school previously, please write N/A in the box for High School #1.
Name of Previous High School #1
City of High School #1
Last Year Student Attended High School #1
Name of Previous High School #2 (if applicable)
City of High School #2
Last Year Student Attended High School #2
Name of Previous High School #3 (if applicable)
City of High School #3
Last Year Student Attended High School #3
Check the box below if you were born outside the U.S. and its territories and enrolled less than 3 cumulative years in the U.S.

Student was born outside the U.S. and its territories and has been enrolled for less than 3 cumulative years in the U.S.
What date did you first enroll in school in the U.S.? (If unsure, please give your best estimate.) *

Month Day Year
Date
What date did you first enroll in the California School System? (If unsure, please give your best estimate.) *

Month Day Year
Date
What school year did you initially enter 9th grade? (Ex: 2019-2020) *

APLUS+ Schools Home Survey
Do you have access to a computer at home? *

Yes No
Do you have access to the Internet from home? *

Yes No
How many times have you moved in the past 12 months? *

Release Survey
1. I grant the school permission to use audio/video of me for school purposes. *

Yes No
2. I grant the school permission to use pictures of me for school purposes *

Yes No
3. I grant the school permission to use work produced by me for school purposes. *

Yes No

Agriculture and Gifted/Talented Survey
Are you or your parent/guardian employed in one or more agricultural or fishing activities on a seasonal or other temporary basis (migrant worker)? *

Yes No
If YES, enter the Migration Number below:
Have you ever taken a standardized test and been identified as gifted? *

Yes No
I certify that all of the statements and information given above and in the previous two sections are true and correct to the best of my knowledge:
Signature *

Clear
Date *

Month Day Year
Date

Master Agreement
YouthBuild Charter School of California is a school of CHOICE. When you sign this agreement, you are agreeing that you choose this school over all others you are entitled to attend or have your child attend. YouthBuild Charter School of California is WASC accredited.
Student’s Full Name (Please Print) *
Effective Date *

Month Day Year
Date
Student's Signature *

Clear
Date *

Month Day Year
Date

Student Release Form
My name: *
Age: *
Date of Birth *

Month Day Year
Date
Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
As an adult student (18 and over) you may give permission to YouthBuild Charter School to release your student information to the certain individuals at your discretion (your parents/guardians, spouse, etc.) Student records may include attendance records, grade reports, discipline reports and any other information that pertains to my progress. If you would like to give your permission for any individuals to access your student records, please list their names below. Otherwise, you can leave the sections below blank.

I give permission to YouthBuild Charter to release my student information to the individuals listed below:
Name of Individual #1
Relationship to Individual #1
Name of Individual #2
Relationship to Individual #2
Name of Individual #3
Relationship to Individual #3
Signature *

Clear
Date *

Month Day Year
Date

Emergency Information 2022-23
Student's Name *

First Name Middle Name Last Name
Date of Birth *

Month Day Year
Date
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Physical Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
IN CASE OF EMERGENCY, PLEASE CONTACT:
Name of Emergency Contact #1 and relationship (ex: mother, spouse, etc.) *
Ex: Jane Doe, Mother
Home/Cell Phone of Emergency Contact #1 *
Work Phone of Emergency Contact #1
Name of Emergency Contact #2 and relationship (ex: aunt, friend, etc.)
Ex: John Doe, Grandfather
Home/Cell Phone of Emergency Contact #2
Work Phone of Emergency Contact #2

Local Educational Agency Name Housing Questionnaire
Name *

First Name Middle Name Last Name
The information provided below will help the LEA determine what services you and/or your child may be eligible to receive. This could include additional educational services through Title I, Part A and/or the federal McKinney-Vento Assistance Act. The information provided on this form will be kept confidential and only shared with appropriate school district and site staff.
Presently, are you and/or your family living in any of the following situations? Check all that apply:

Staying in a shelter (family shelter, domestic violence shelter, youth shelter) or Federal Management Agency (FEMA) trailler Sharing housing with other(s) due to loss of housing, economic hardship, natural disaster, lack of adequate housing, or similar reason Living in a car, park, campground, abandoned building, or other inadequate accommodations (i.e. lack of water, electricity, or heat) Temporarily living in a motel or hotel due to loss of housing, economic hardship, natural disaster, or similar reason Living in a single-home residence that is permanent I am a student under the age of 18 and living apart from parent(s) or guardian
Head of Household's Name (this may be the student's name or the name of parent/guardian if student lives at home) *
Signature *

Clear
Date *

Month Day Year
Date
Phone Number *
Street Address *
City *
State *
Zip *
Your child or children may have the right to:
- Immediate enrollment in the school they last attended (school of origin) or the local school where you are currently staying, even if you do not have all documents normally required at the time of enrollment.
- Continue to attend their school of origin, if requested by you and it is in the best interest of the student.
- Receive transportation to and from their school of origin, the same special programs and services, if needed, as provided to all other children, including free meals and Title I.
- Receive the full protections and services provided under all federal and state laws, as it relates to homeless children, youth, and their families.

Please list all children currently living with you.

	Name	M/F	Birthdate	Grade	School
Child 1
Child 2
Child 3

If you have any questions about these rights, please contact the local homeless liaison, Tizoc Brenes, by phone at 213-741-2600 or by email at tbrenes@youthbuildcharter.org.

Informed Consent and Limits of Confidentiality
This letter is intended to inform and request your consent for yourself or your son/daughter to receive counseling services at our school site. The MSW interns along with a licensed clinician will provide assistance through case management, one-on-one counseling, crisis intervention, behavioral counseling, group counseling, telehealth, and workshops. If a need for treatment beyond the scope of services provided on site arises, you will be contacted to consent for such services. The intent is to provide support for yourself and/or your son/daughter, the school, and your family. The intern will complete documentation including progress notes, psychosocial assessments, and goals and is kept in a HIPAA compliant electronic records system. The intern will only be working with the student until the end of the school year unless the student voluntarily discontinues the service. At the end of the intern’s internship the intern will end communication with clients in order to ensure confidentiality.

The intern works on a team with school staff and will need to notify staff of the working relationship between the intern and student and the basic services offered to the student. No other specific information regarding sessions will be provided to the school unless verbal consent is given by the student to do so.

Electronic communication is allowed between MSW interns and clients for appointment/attendance reminders and for counseling sessions. Clients may not engage in electronic communications with interns outside of regular school day or for any other therapeutic reason including crises.

During the process of providing these services all information exchanged will be kept confidential. Protected health information will not be shared with anyone outside of the school unless you or your son/daughter and/or parent sign a consent authorizing release of information.

The following are exceptions to this policy:
- Anyone working with a minor is required by law to:
  - Report any reasonable suspicion of child, elder , or dependent abuse to the appropriate county agency.
  - Notify an appropriate person and/or agency if the student indicates intent to physically harm him/herself or someone else.
If you have any questions or need further clarification please feel free to ask.
I, Type Student's Full Name Here , hereby certify that I have read the above and understand that I may meet with an MSW for counseling services.

I, Type Student's Full Name Here*, hereby certify that I understand the limitations of confidentiality and electronic communications.
Student's Signature *

Clear
Date *

Month Day Year
Date

NONDISCRIMINATION STATEMENT
YouthBuild Charter School of California (YCSC) is committed to providing a working and learning environment free from discrimination, harassment, intimidation, abusive conduct or bullying. YCSC prohibits discrimination, harassment, intimidation, abusive conduct or bullying based on actual or perceived race or ethnicity, gender/sex (including gender identity, gender expression, pregnancy, childbirth, breastfeeding/lactation status and related medical conditions), sexual orientation, religion, color, national origin (including language use restrictions and possession of a driver’s license issued under Vehicle Code), ancestry, immigration status, medical information, physical or mental disability (including clinical depression and bipolar disorder, HIV/AIDS, hepatitis, epilepsy, seizure disorder, diabetes, multiple sclerosis, and heart disease), medical condition (cancer related and genetic characteristics), military and veteran status, parenting status, marital status, registered domestic partner status, age (40 and above), genetic information, political belief or affiliation (unless union related), a person's association with a person or group with one or more of these actual or perceived characteristics, or any other basis protected by federal, state or local law, ordinance, or regulation in any program or activity it conducts or to which it provides significant assistance.

Discrimination is different treatment on the basis of a protected characteristic in the context of an educational program, work or activity without a legitimate nondiscriminatory reason that interferes with or limits the individual’s ability to participate in or benefit from the services, activities, or privileges provided by YCSC or includes an adverse employment action.

Hostile environment harassment occurs when a target is subjected to unwelcome conduct on the basis of a protected characteristic, which is both subjectively offensive to the target and would be offensive to a reasonable person of the protected characteristics under similar circumstances, and is sufficiently severe, persistent, or pervasive so as to interfere with or limit an individual’s ability to effectively work or to participate in or benefit from the services, activities or opportunities offered by YCSC. Harassment may take many forms, including but not limited to, verbal remarks and name calling, graphic and written statements, or any conduct that may be threatening or humiliating. Harassment based on any of the above-protected categories is a form of unlawful discrimination and will not be tolerated by YCSC and can result in disciplinary action against the offending student or employee.

Upon witnessing an act of discrimination, harassment, intimidation, abusive conduct or bullying based on actual or perceived protected characteristics, school personnel are required to take immediate steps to intervene when it is safe to do so. Once a school/office has express notice or reason to know of such conduct, whether carried out by employees, students or third parties, it should take immediate and appropriate steps to investigate or otherwise determine what occurred and take prompt and effective steps reasonably calculated to end the conduct, eliminate a hostile environment, if one has been created and prevent the conduct from occurring again. These steps should be taken regardless of whether an individual makes a complaint or asks the school/office to take action. Complainants are protected from retaliation. YCSC prohibits retaliation against any person who files a complaint or an appeal, reports instances of noncompliance, discrimination, harassment, intimidation, abusive conduct or bullying, or who participates in the complaint-filing or investigation process. This nondiscrimination policy applies to all acts related to school activity or school attendance within any school/office under the jurisdiction of the Superintendent of YouthBuild Charter School of California.

For inquiries or complaints related to discrimination, harassment, intimidation or bullying of students based on actual or perceived protected characteristics, contact the Title IX/Bullying Complaint Manager:

Dr. Rudy Cuevas
155 W. Washington Blvd., Suite 944
Los Angeles, CA 90015
213.741.2600. ext. 205
RCuevas@youthbuildcharter.org

For inquiries or complaints related to employee-to-employee, student-to-employee, or work/employment related discrimination, harassment, abusive conduct or intimidation, contact your Human Resources Department.
Should be Empty:

Fresno Site 2022 – 2023 Enrollment Application

Once you have completed this online application you must submit the above documents to your counselor in order to complete your enrollment.

Student Information:

Race/Ethnicity Surveys

PREVIOUS SCHOOLING INFORMATION

Parent/Guardian Education Level Survey

HOME LANGUAGE SURVEY

Dashboard Alternative School Status (DASS)

APLUS+ Schools Home Survey

Household Income Data Collection

Release Survey

Special Education Services/ 504 Plan

Agriculture and Gifted/Talented Survey

Master Agreement

Student Release Form

Emergency Information 2022-23

IN CASE OF EMERGENCY, PLEASE CONTACT:

Health Information

Local Educational Agency Name Housing Questionnaire

Informed Consent and Limits of Confidentiality

NONDISCRIMINATION STATEMENT